EMS World

AUG 2011

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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CE ARTICLE Pericarditis is the most common cardiac manifestation of SLE, occurring in about 30% of patients with the disease.10 Atherosclerosis can occur prematurely in patients with the disease and is an independent risk factor for cardiovas- cular disease. Pulmonary hypertension, vasculitis and splinter hemorrhages can also occur. Pleural effusions are common, and patients whose SLE is treated with immunosuppressive agents are at high risk for opportunistic bacterial, viral and fungal pulmonary infections. Headaches are the most common central nervous system manifestation of SLE, occurring in up to 61% of adults and 72% of children who have it.11 All types of seizures have been reported, with grand mal seizures being the most common. Mental disorders are common, and about 20%–40% of neuropsychiatric SLE fi ndings arise prior to or right around the time of diagnosis.11 Patients with SLE are also at high risk for stroke, especially in the fi rst fi ve years of the disease. With so many body systems involved in SLE, and with such widespread clin- ical manifestations, it’s easy to imagine that most prehospital care providers will encounter a patient with acute manifes- tations of new onset or chronic SLE with some frequency in their careers. While the EMS provider would not be expected to diagnose SLE in the fi eld, it is benefi - cial to recognize that the patient with SLE has a compromised immune system and is at high risk for infection. There is no specifi c prehospital treatment for SLE. Treatment is supportive in nature only, and any acute complication like pericarditis, stroke or seizure should be managed in the appropriate manner. Immunocompromised Patients Compared to patients with a healthy immune system, infections in immuno- compromised patients are more common, more severe, progress more rapidly, are more often fatal, and are caused by a wider variety of sometimes rare organ- isms.12 There are many factors that can result in immunosuppression, including disruption of the skin and mucosal surfaces (burn patients, patients with gastrointestinal lesions or disease), derangements in organ function (liver, spleen, kidneys), medical disorders that directly impair the function of the immune system (HIV, lymphoma, other cancers), and treatments for disease and trans- plant rejection (medications, radiation). It is important for the EMS provider to recognize those individuals with a poten- tially compromised immune system, as it should directly impact the decision- making process regarding transport to an ED for evaluation or recommendations for follow-up with a personal physician if the patient refuses transport. In such cases, it is advantageous for the EMS provider to be aware of the patient populations with a propensity for immunocompromise so the patient can be informed of the risks involved in not seeking medical attention for something like a low grade fever that seems non-emergent. Immunocompromised States ORGAN TRANSPLANTS In recent years, the number of organ transplants (kidney, lung, heart and liver) performed has been limited only by the number of available donors. With one-year survival rates for all solid organ transplants exceeding 80%, more patients are surviving longer, and subse- quently more patients are experiencing complications that bring them into contact with EMS and the ED.12 Lifelong immunosuppression is gener- ally required for all patients who have undergone organ transplants. Without immunosuppression, the transplanted organ would be identifi ed as “non-self” by the host immune system and its cells and tissues targeted for destruction. Because of this need for immunosuppression, organ transplant patients are at high risk for infection, which is the primary cause of mortality after transplantation. Two-thirds of all transplant patients will have at least one signifi cant infection post-transplant.13 Signs of infection in the transplant patient can be diffi cult to detect for a number of reasons. Transplanted organs are commonly denervated—in other words, devoid of their normal innervation. Subsequently, the patient is much less likely to experience the pain in and around that organ as typically experienced during a developing organ infection. In addition, the normal infl ammatory response will be blunted due to the use of immunosup- pressive medications. As a result of these complications, constitutional signs and symptoms of developing infection such as a fever could be subtle and easily over- looked or discounted. Seemingly harmless complaints may be the only indication of severe infection and the need for aggres- sive management in the ED. CANCER Patients with cancer commonly have multiple insults to their immune system, particularly T and B cell impairment as a result of the disease process, chemo- therapy and radiation therapy. Other factors that contribute to an increased risk of infection include the breakdown of physical barriers such as the skin and mucous membranes secondary to the disease and the effects of chemo- therapy, and the frequent colonization of antimicrobial-resistant pathogens (MRSA, VRE) on the skin and gastrointes- tinal surface. In addition, cancer patients may have a central venous catheter or other indwelling device that serves as a conduit for pathogens into the body. These patients frequently undergo invasive diagnostic and therapeutic procedures that break the skin and increase the risk of infection. Infection is more common in patients with new-onset leukemia, lymphoma and myeloma compared to patients with solid tumors.14 DIABETES Diabetics have multiple impairments that increase the risk of acquiring an infec- tion that can subsequently go undetected. Neutrophil and macrophage functions are impaired in this population, resulting in the immune cells being less effective at adhering to and destroying pathogens that enter the host. These defects are exacerbated by poor blood glucose main- tenance that results in hyperglycemia. The reason why is not completely understood. After contracting an infection, the diabetic patient is at high risk for the infection to EMSWORLD.com | AUGUST 2011 49

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